Fluid balance error in continuous renal replacement therapy: A technical note

Background. The reliability and safety of continuous renal replacement therapy (CRRT) machines have improved, yet there still remains the potential for fluid balance errors to occur during treatment. Methods. In vitro testing of two Kimal Hygieia CRRT machines (Plus and Ultima) was performed. Normal saline to simulate the blood circuit and standard bicarbonate-based fluid for replacement were used. All tests were performed in CVVH mode at four ultrafiltration (UF) rates. The testing was based on creation of a voluntary fluid balance error by clamping the line that fills the replacement fluid chamber to stop flow to the (simulated) patient. The time to alarms and fluid balance errors were recorded. The alarms were overridden and the accumulated fluid balance error allowed by the machine was determined. Results. The alarm occurred approximately 1 minute after the replacement fluid line was clamped at all UF rates. There was no limit to the number of times the alarm could be overridden and the accumulated negative fluid balance was proportional to the prescribed UF rate. After the replacement fluid chamber was allowed to re-fill, the machine attempted to correct the fluid deficit and consistently delivered excess fluid to generate a positive fluid balance error. Conclusions. The Hygieia machines appear designed with appropriate alarm and safety features. However, simulated fluid balance errors raise caution for operators. Clinicians and nurses need to understand the clinical implications of alarm overrides. Fluid balance errors caused by failure to acknowledge and correct replacement fluid failure alarms may cause harm to patients.